JMU School of Nursing

Spring 2017
NSG 352L Preplanning Form with Detailed Careplan

Careplan
Directions: There are 5 steps to the nursing process: Assessment,
diagnosis, planning, implementation and evaluation. You will begin here the
night before clinical by creating your plan based upon the information
gleaned during pre-planning. THEN, you will implement during clinical.
Lastly, you will evaluate your plan in the last section of this document.
About interventions: Consider what you will need to do to care for the
patient. Include activity, safety, mobility and teaching in this plan. Also
consider any physical care requirements needed such as bathing, dressing,
feeding, repositioning, dressing changes, ambulation, oral care, sensory aids
and assistive devices. You need a minimum of 2 in each intervention box.

NURSING EXPECTED ASSESSME ACTION TEACHING

DIAGNOSES PATIENT NT interventio interventio
OUTCOMES interventio ns: ns: (consider
(note priority
ns: (consider home
for each Be sure they
orders, regimens,
below) are S. M. A. R. (assess /
safety, procedures,
T. (Specific, monitor for
(Be sure to allergies, discharge
measureable, )
use related code status, plan, etc.)
achievable/
to and as fall risk, etc.)
attainable,
evidenced
relevant and
by)
time-bound)
Impaired Patient will Assess Ensure Educate
physical position legs changes in patient is patient on
mobility r/t correctly and vital signs, wearing the
decrease in independently including appropriate challenges
muscle on pivot board pulse and footwear that may
strength three times by respirations, (non-slide arise if the
AEB inability end of shift. with shoes) board does
to ambulate exertional during not rotate.
Patient will lift
unassisted activities transfers.
legs off of Educate
and need for such as leg
wheelchair and Ensure patient on
two person lifting and
hold them in patient is importance
assist, pivot transfers.
the air for 10 placing feet of placing
board, and
seconds three Monitor for squarely on feet correctly
wheelchair
times by end of unequal pivot board, on board.
for mobility
shift. strength in and not
 JMU School of Nursing
Spring 2017
NSG 352L Preplanning Form with Detailed Careplan
devises. legs; allowing the Explain to
monitor for right foot to patient how
less rest with the pivot
movement toes curved board as well
and strength inward and as her
in the right ankle rolling increased
leg. away from muscle
body. strength can
help the
Promote
CNAs,
flexion
therapists,
extension of
and nurses
knees and
with
hips,
transfers.
encouraging
active range
of motion on
the left side,
and active-
passive on
the right
side.
Activity Resident will Monitor for Encourage Educate the
intolerance perform the use of resident on
Monitor for
r/t difficult respiratory an acapella the benefits
changes in
and labored toileting using before of using
vital signs,
breathing an incentive Occupationa respiratory
including
AEB spirometer l Therapy toileting
respirations
exertional and/or an and Physical devices to
and SpO2,
discomfort acapella 2 Therapy to reduce the
before and
and times, 10 clear mucus wheezing
after
increased passes each and promote sound while
exertion.
respiratory time, by the easier talking.
rate end of shift. breathing.
Explain to
following
Ensure the the resident
transfers
resident is that labored
and
sitting with breathing
toileting.
correct can be
posture to significantly
help with improved
expansion of with
 JMU School of Nursing
Spring 2017
NSG 352L Preplanning Form with Detailed Careplan
the lungs. respiratory
exercise, and
Promote
is not
strong, deep
something to
coughs to
fear.
expel mucus
from the
lungs.